UKZN Partners with ECHO India for Nephrology Outreach Services in KZN

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The School of Clinical Medicine has partnered with an international outreach project, the Extension for Community Healthcare Outcomes (The ECHO Institute) at the University of New Mexico (Albuquerque, USA), and ECHO India to strengthen its reach to healthcare professionals in peripheral hospital sites in KwaZulu-Natal (KZN). Project ECHO was launched in 2003 by Dr Sanjeev Arora, and currently has more than 90 hubs in Africa including the one established at UKZN which is focused on medical outreach services. The Adult and Paediatric Nephrology Outreach programme was recently launched under this banner.

Dean of Clinical Medicine, Professor Ncoza Dlova, introduced the School’s healthcare specialists to the ECHO Outreach movement based on a mentor-mentee model that uses technology to leverage scarce resources; share best practices to reduce disparities; applies case-based learning to master complexities; and evaluates and monitors outcomes. Capacitating primary healthcare practitioners, strengthening outreach and creating self-sustaining healthcare services in rural communities are all part of the movement’s core mission.

ECHO Project Manager at UKZN, Dr Serela Ramklass said, ‘We are excited to partner with the ECHO Institute and ECHO India to facilitate the link between primary care clinicians at hospitals across the province with specialist staff from the School of Clinical Medicine. Collectively, we can improve the health outcomes and quality of life in patients at peripheral sites through shared knowledge on patient assessment and management through mentoring and feedback.’

Team leader for the Adult and Paediatric Nephrology UKZN-ECHO programme, Professor Rajendra Bhimma said, ‘We will focus on nephrology conditions (both paediatric and adult) which are most common in our region. The discussions will be general, allowing all regional hospitals and district hospitals to participate. The project will deal with clinical cases presented by doctors either at the central or peripheral hospital, followed by a clinicopathological discussion around the case. In this way, doctors at peripheral hospitals will be able to participate in the discussion and be updated on the acute and chronic management of the patient. Optimal management of the patient at the base hospital before transfer to the higher care facility will greatly improve the outcome of these patients.’

Dr Sudesh Hariparshad, Head of UKZN and Inkosi Albert Luthuli Central Hospital Nephrology noted there is one nephrologist per 2.5 million people in South Africa. ‘It is important to note that Chronic Kidney Disease (CKD) in its early stages is a silent disease and may only become apparent when more than 50% of kidney function is lost. It is therefore essential that patients be screened, managed and referred appropriately at the primary healthcare level.

‘Furthermore, CKD is the fifth highest cause of death in low- and middle-income countries. The main risk factors in South Africa are hypertension, Diabetes Mellitus and HIV. At the tertiary level, we see patients at an advanced stage of the disease, 99% of whom are in phases 3-5. It is therefore vital that sufficient urinary testing is done at the primary healthcare level to assess for albuminuria or proteinuria which is vital to risk stratify patients. Other markers include low estimated glomerular filtration rate (EGFR) and raised protein excretion which are associated with a massive (15 -16 times) greater likelihood of advanced CKD or End Stage Kidney disease.’

Academic Leader of Medical Registrars at UKZN and Head of the Clinical Unit of Paediatrics at King Edward VIII Hospital, Dr Kimesh Naidoo presented on Glomerulonephritis (GN), a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue resulting in damage to the basement membrane, mesangium, capillary endothelium and epithelium. Naidoo presented a case study of an 11-year-old patient who presented at a local clinic with “coke-like” or “tea-coloured” urine, a slight headache and no health issues at school. He was discharged but presented a week later with mild pedal oedema, high blood pressure (BP), and macroscopic haematuria. At this stage, he was diagnosed with nephritis.

Naidoo commented, ‘Determining when such cases require referral to specialists and sub-specialist levels of care with most cases of nephritis can be adequately managed at primary healthcare levels.’

Bhimma stressed the importance of examining urine. ‘Persistent protein in urine is very toxic to the kidney. Another marker to be aware of is haematuria when there is more than 5% dysmorphic or crenated (abnormally shaped) red blood cells in urine. It is important to follow up on patients to assess whether their BP is controlled, kidney function is normal and there is no protein in the urine. Furthermore, it is important to note that in stage 3 or less of CKD, there are often no major symptoms. However, screening for CKD is essential as patients often present to nephrologists when they experience kidney failure. Proper management in the early stages including diet, exercise, weight loss and cholesterol management may delay progression or prevent CKD.’

Naidoo said, ‘There is potential to integrate the ECHO programme with primary healthcare doctors (medical officers and doctors completing community service in district and regional facilities) with their human resources development portfolios that are required as Department of Health employees.’ 

The next ECHO workshop scheduled for June will focus on hypertension in adults and children. Contact Dr Serela Ramklass for further details at ramklasss@ukzn.ac.za.

Words: MaryAnn Francis

Photograph: Supplied